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CLINICAL ETHICS

Patient consultation survey in an ophthalmic outpatient department

S A Aslam, P Colapinto, H G Sheth, R Jain
................................................................................................................................... J Med Ethics 2007;33:134135. doi: 10.1136/jme.2006.016899

See end of article for authors affiliations ........................ Correspondence to: S Aslam, Eye Department, Chelsea and Westminster Hospital, Fulham Road, London SW10 9NH, UK; sheraslam2@yahoo.com Received 29 March 2006 Revised 31 March 2006 Accepted 6 April 2006 ........................

Introduction: Consultation methods differ between medical practitioners depending on the individual setting. However, the central tenet to the doctorpatient relationship is the issue of confidentiality. This prospective survey highlights patient attitudes towards consultation methods in the setting of an ophthalmic outpatient department. Method: Questionnaires were completed by 100 consecutive patients, who had been seen by an ophthalmologist in a single room, which had a joint doctorpatient consultation occurring simultaneously. Results: Each question of all 100 questionnaires was completed. 58% of patients were not concerned about sharing a consultation room with another patient or doctor. However, this did not equate to the 49% of patients who were indifferent to discussing issues in the joint consultation room. The most common factor was the general issue of confidentiality. Discussion: Ensuring total patient confidentiality may be deemed more necessary for certain medical specialties than for others, as seen in the practice of separate medical records in genitourinary medicine, for instance. However, with regard to patient consultations, the same level of confidentiality should be afforded across all specialties, and such factors should be borne in mind when planning outpatient clinics. cause for concern in patients: general issue of confidentiality (28%); discussion of general or family health problems (12%); and discussion of eye complaints (6%). In all, 49% were indifferent and although five patients checked the tick box marked other for this question, there were no specific details as to what these other factors entailed. Assessment by the same doctor at each visit showed varied results (table 1), although most patients (64%) would have preferred continuity of care. In total, 79% of patients preferred to receive a copy of correspondence as sent to the general practitioner and 21% had no preference regarding this.

onsultation methods differ between medical practitioners depending on the situation. However, in all cases, the emphasis should be on achieving the optimal environment for a fully informed consultation. The issue of confidentiality is a central tenet of the doctorpatient relationship. With respect to this, factors including teaching of medical students need to be taken into account to achieve the best outcome for all the people concerned. Numerous reports are available on consultation methods in certain specialties, especially in general practice. However, the literature on similar issues in ophthalmic practice is limited and there is no previous survey on patient assessment of ophthalmic consultation methods. This report provides such data to understand patient concerns about an important issue.

DISCUSSION
A central theme in the practice of medicine is the trust between patients and doctors with regard to the issue of confidentiality. In the UK, the General Medical Council guidelines stipulate that information held by doctors about patients is private and sensitive, and must not be given to others unless the patient consents or the disclosure can be justified.1 Disclosure of patient information is subject to the following exceptions: sharing of information within the healthcare team or with others providing care; disclosure of information for clinical audit; disclosures in connection with judicial or other statutory proceedings; disclosures in the public interest; disclosures to protect the patient or others, or in situations where children and other patients may lack competence to give consent; and disclosures in certain instances after a patients death. During consultations carried out in the outpatient setting, ensuring total patient confidentiality may be deemed more necessary for certain medical specialties than for others, as seen in the practice of separate medical records in genitourinary medicine, for instance. Conversely, certain factors may limit the degree of discretion afforded to each consultation. According to the results of this study, the most frequent concern of patients in this consultation setting was the issue of confidentiality (table 1). There were also issues regarding the availability of working space and teaching of medical students, the availability of working space being a resource-dependent yet

METHOD
A prospective survey of 100 consecutive patients seen in the ophthalmic outpatient department included a questionnaire for each patient. All patients had undergone consultation by an ophthalmologist in an examination room shared with another ophthalmologist or patient. All questionnaires were completed away from the examining doctor to avoid bias. Medical students were present for each case. Questions asked of the patients dealt with the following issues: presence of medical students; consultation in a single room with another doctor or patient consultation occurring concurrently; continuity of care; and correspondence.

RESULTS
Each question of all 100 questionnaires was completed. As shown in table 1, 79.0% patients had no concerns regarding the presence of medical students and 52.0% had no issues with their being examined by medical students. Surprisingly, although 58% of patients were not concerned about sharing a consultation room with another patient or doctor, this did not equate to the 49% of patients who were indifferent to discussing issues in the joint consultation room. As regards discussion of issues in this setting, the following factors were a
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Ophthalmic outpatient survey

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Table 1

Patients degree of concern per factor (n = 100 per factor)

Degree of concern (no of patients) Nil Mild 8 29 13 13 Moderate 6 14 16 29 Extreme 7 5 13 22

Presence of medical students Examination by medical students Consultation in joint room Different examining doctor per appointment

79 52 58 36

manageable factor, whereas the teaching of medical students is a fundamental part of undergraduate training. Medical undergraduate training through observation of clinical skills in the outpatient setting and through examination of patients is vital to acquire an appropriate level of skills before qualifying. This aspect must be emphasised to each patient before consultation. In addition to reminding qualified health professionals including doctors themselves of the issue of confidentiality, this should also be reiterated to undergraduates to prevent inadvertent breaches of patient confidentiality owing to inadvertence or ignorance.2 It is reassuring that, as shown by this study, most patients do not have concerns about being examined by medical students. However, continuity of care is a perennial problem in hospital departments, especially with a regular turnover of junior medical staff. Concern that discontinuity leads to a lack of personal and case familiarity and communication difficulties is an issue for patients.3 According to our study, 64% of patients had concerns about being examined by a different doctor on each visit. It is advisable to ensure consultation with the same member of staff on followup where possible, to improve this situation. Interestingly, 79% of our patients requested a copy of the correspondence letter. It is good medical practice to ensure that each patient is kept fully informed of all decisions pertaining to their medical care. One way is to copy a precis of the correspondence to each patienttime and resources permitting. However, White et al4 conducted a study via patient interviews, concluding that although copying referral letters to patients can improve information and decision sharing with patients, providing more information to patients may increase patient anxiety, especially with the use of sensitive medical terminology.

The importance of patient satisfaction is the cornerstone of health delivery and, as such, surveys are designed to highlight relevant findings.5 Our survey shows that patients thoughts about consultation methods are diverse, as we had expected. It underlines the need to maintain confidentiality even when conflicting factors such as working space are an issue. It also provides an insight into the need for all medical specialties to be considered on a par with respect to these factors, ophthalmology included. This should direct health service providers towards providing a more patient-centric framework to deal with these concerns. It is also important to ensure that the examining doctor takes these concerns into account to achieve the best possible practice.
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Authors affiliations

S A Aslam, P Colapinto, H G Sheth, R Jain, Eye Department, Chelsea and Westminster Hospital, London, UK Competing interests: None.

REFERENCES
1 General Medical Council. Confidentiality: protecting and providing information, 2004. http://www.gmc-uk.org/standards/secret.htm. 2 Elger BS, Harding TW. Avoidable breaches of confidentiality: a study among students of medicine and of law. Med Educ 2005;39:3337. 3 Adewuyi-Dalton R, Ziebland S, Grunfeld E, et al. Patients views of routine hospital follow-up: a qualitative study of women with breast cancer in remission. Psychooncology 1998;7:4369. 4 White P, Singleton A, Jones R. Copying referral letters to patients: the views of patients, patient representatives and doctors. Patient Educ Couns 2004;55:948. 5 Hacker MR, Primeaux J, Manco-Johnson MJ. A patient satisfaction survey for haemophilia treatment centres. Haemophilia 2006;12:1638.

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